Single-molecule investigations of single-chain cellulose biosynthesis.

Cellulose biosynthesis in sessile bacterial colonies originates in the membrane-integrated bacterial cellulose synthase (Bcs) AB complex. We utilize optical tweezers to measure single-strand cellulose biosynthesis by BcsAB from Rhodobacter sphaeroides. Synthesis depends on uridine diphosphate glucose, Mg2+, and cyclic diguanosine monophosphate, with the last displaying a retention time of ∼80 min. Below a stall force of 12.7 pN, biosynthesis is relatively insensitive to force and proceeds at a rate of one glucose addition every 2.5 s at room temperature, increasing to two additions per second at 37°. At low forces, conformational hopping is observed. Single-strand cellulose stretching unveiled a persistence length of 6.2 nm, an axial stiffness of 40.7 pN, and an ability for complexes to maintain a tight grip, with forces nearing 100 pN. Stretching experiments exhibited hysteresis, suggesting that cellulose microstructure underpinning robust biofilms begins to form during synthesis. Cellohexaose spontaneously binds to nascent single cellulose strands, impacting polymer mechanical properties and increasing BcsAB activity.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review.

PURPOSE: To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures. METHODS: Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.). RESULTS: Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS. CONCLUSIONS: The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

TEMPORARY REMOVAL: Favorable and Durable Outcomes at 10-Year Follow Up After Endoscopic Gluteus Medius Repair With Concomitant Hip Arthroscopy.

The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

Metrics of student dissatisfaction and disagreement: longitudinal explorations of a national survey instrument.

This study explores dissatisfaction and neutrality metrics from 12 years of a national-level undergraduate student survey. The notion of dissatisfaction is much less prevalent in the narratives surrounding student survey outcomes, and the underpinning metrics are seldom considered. This is despite an increasingly vociferous debate about 'value for money' of higher education and the positioning of students as consumers in a marketised sector. We used machine learning methods to explore over 2.7 million national survey outcomes from 154 institutions to describe year-on-year stability in the survey items that best predicted dissatisfaction and neutrality, together with their similarity to known metric predictors of satisfaction. The widely publicised annual increases in student 'satisfaction' are shown to be the result of complex reductions in the proportions of disagreement and neutrality across different survey dimensions. Due to the widespread use of survey metrics in university league tables, we create an anonymised, illustrative table to demonstrate how UK institutional rankings would have differed if dissatisfaction metrics had been the preferred focus for reporting. We conclude by debating the tensions of balancing the provision of valuable information about dissatisfaction, with perpetuating negative impacts that derive from this important subset of the survey population.

An investigation into the impact of nine catchment characteristics on the accuracy of two phosphorus load apportionment models.

Phosphorus (P) load apportionment models (LAMs), requiring only spatially and temporally paired P and flow (Q) measurements, provide outputs of variable accuracy using long-term monthly datasets. Using a novel approach to investigate the impact of catchment characteristics on accuracy variation, 91 watercourses' Q-P datasets were applied to two LAMs, BM and GM, and bootstrapped to ascertain standard errors (SEs). Random forest and regression analysis on data pertaining to catchments' land use, steepness, size, base flow and sinuosity were used to identify the individual relative importance of a variable on SE. For BM, increasing urban cover was influential on raising SEs, accounting for c.19% of observed variation, whilst analysis for GM found no individually important catchment characteristic. Assessment of model fit evidenced BM consistently outperformed GM, modelling P values to ±10% of actual P values in 85.7% of datasets, as opposed to 17.6% by GM. Further catchment characteristics are needed to account for SE variation within both models, whilst interaction between variables may also be present. Future research should focus on quantifying these possible interactions and should expand catchment characteristics included within the random forest. Both LAMs must also be tested on a wide range of high temporal resolution datasets to ascertain if they can adequately model storm events in catchments with diverse characteristics.

Scatological Asklepios: The Use of Excrement in Graeco-Roman Healthcare.

In the classical world, "official" rationalistic medicine made therapeutic use of excrement, urine and other substances that modern humans normally regard as repulsive (this was even true of Galen, the culminating authority); and popular medicine seems to have done so on a large scale. Such practices, which finally lost their professional though not their popular acceptability in the 18th century, have been studied to good purpose by other historians, but they have never been explained in a satisfactory fashion, partly because the relevant evidence is highly diverse. The present paper, by considering the long term (pre-Greek as well as Greek and Roman) and all the relevant contexts, including ancient feelings of disgust and the general state of ancient pharmacology, and by probing people's subconscious motives, attempts to establish a multi-factor explanation. This explanation balances traditions, beliefs about the inherent qualities, physical and magical, of natural substances, and the psychological needs of both healers and the sick.

The wicked problem of healthcare student attrition.

The early withdrawal of students from healthcare education programmes, particularly nursing, is an international concern and, despite considerable investment, retention rates have remained stagnant. Here, a regional study of healthcare student retention is used as an example to frame the challenge of student attrition using a concept from policy development, wicked problem theory. This approach allows the consideration of student attrition as a complex problem derived from the interactions of many interrelated factors, avoiding the pitfalls of small-scale interventions and over-simplistic assumptions of cause and effect. A conceptual framework is proposed to provide an approach to developing actions to reduce recurrent investment in interventions that have previously proved ineffective at large scale. We discuss how improvements could be achieved through integrated stakeholder involvement and acceptance of the wicked nature of attrition as a complex and ongoing problem.

Phase III randomized study of second line ADI-PEG 20 plus best supportive care versus placebo plus best supportive care in patients with advanced hepatocellular carcinoma.

Background: Arginine depletion is a putative target in hepatocellular carcinoma (HCC). HCC often lacks argininosuccinate synthetase, a citrulline to arginine-repleting enzyme. ADI-PEG 20 is a cloned arginine degrading enzyme-arginine deiminase-conjugated with polyethylene glycol. The goal of this study was to evaluate this agent as a potential novel therapeutic for HCC after first line systemic therapy. Methods and patients: Patients with histologically proven advanced HCC and Child-Pugh up to B7 with prior systemic therapy, were randomized 2 : 1 to ADI-PEG 20 18 mg/m2 versus placebo intramuscular injection weekly. The primary end point was overall survival (OS), with 93% power to detect a 4-5.6 months increase in median OS (one-sided α = 0.025). Secondary end points included progression-free survival, safety, and arginine correlatives. Results: A total of 635 patients were enrolled: median age 61, 82% male, 60% Asian, 52% hepatitis B, 26% hepatitis C, 76% stage IV, 91% Child-Pugh A, 70% progressed on sorafenib and 16% were intolerant. Median OS was 7.8 months for ADI-PEG 20 versus 7.4 for placebo (P = 0.88, HR = 1.02) and median progression-free survival 2.6 months versus 2.6 (P = 0.07, HR = 1.17). Grade 3 fatigue and decreased appetite occurred in <5% of patients. Two patients on ADI-PEG 20 had ≥grade 3 anaphylactic reaction. Death rate within 30 days of end of treatment was 15.2% on ADI-PEG 20 versus 10.4% on placebo, none related to therapy. Post hoc analyses of arginine assessment at 4, 8, 12 and 16 weeks, demonstrated a trend of improved OS for those with more prolonged arginine depletion. Conclusion: ADI-PEG 20 monotherapy did not demonstrate an OS benefit in second line setting for HCC. It was well tolerated. Strategies to enhance prolonged arginine depletion and synergize the effect of ADI-PEG 20 are underway. Clinical Trial number: www.clinicaltrials.gov (NCT 01287585).

Neutral variation does not predict immunogenetic variation in the European grayling (Thymallus thymallus)-implications for management.

Preservation of genetic diversity is critical to successful conservation, and there is increasing demand for the inclusion of ecologically meaningful genetic information in management decisions. Supportive breeding programmes are increasingly implemented to combat declines in many species, yet their effect on adaptive genetic variation is understudied. This is despite the fact that supportive breeding may interfere with natural evolutionary processes. Here, we assessed the performance of neutral and adaptive markers (major histocompatibility complex; MHC) to inform management of European grayling (Thymallus thymallus), which routinely involves supplementation of natural populations with hatchery-reared fish (stocking). This study is the first to characterize MH II DAA and DAB loci in grayling and to investigate immune genetic variation in relation to management practice in this species. High-throughput Illumina sequencing of "introduced," "stocked native" and "non-stocked native" populations revealed significantly higher levels of allelic richness and heterozygosity for MH markers than microsatellites exclusively in non-stocked native populations. Likewise, significantly lower differentiation at the MH II than for microsatellites was apparent when considering non-stocked native populations, but not stocked populations. We developed a simulation model to test the effects of relaxation of selection during the early life stage within captivity. Dependent on the census population size and stocking intensity, there may be long-term effects of stocking on MH II, but not neutral genetic diversity. This is consistent with our empirical results. This study highlights the necessity for considering adaptive genetic variation in conservation decisions and raises concerns about the efficiency of stocking as a management practice.

Characterization of the collagen microstructural organization of human cervical tissue.

The cervix shortens and softens as its collagen microstructure remodels in preparation for birth. Altered cervical tissue collagen microstructure can contribute to a mechanically weak cervix and premature cervical dilation and delivery. To investigate the local microstructural changes associated with anatomic location and pregnancy, we used second-harmonic generation microscopy to quantify the orientation and spatial distribution of collagen throughout cervical tissue from 4 pregnant and 14 non-pregnant women. Across patients, the alignment and concentration of collagen within the cervix was more variable near the internal os and less variable near the external os. Across anatomic locations, the spatial distribution of collagen within a radial zone adjacent to the inner canal of the cervix was more homogeneous than that of a region comprising the middle and outer radial zones. Two regions with different collagen distribution characteristics were found. The anterior and posterior sections in the outer radial zone were characterized by greater spatial heterogeneity of collagen than that of the rest of the sections. Our findings suggest that the microstructural alignment and distribution of collagen varies with anatomic location within the human cervix. These observed differences in collagen microstructural alignment may reflect local anatomic differences in cervical mechanical loading and function. Our study deepens the understanding of specific microstructural cervical changes in pregnancy and informs investigations of potential mechanisms for normal and premature cervical remodeling.

"My mentor didn't speak to me for the first four weeks": Perceived Unfairness experienced by nursing students in clinical practice settings.

AIMS AND OBJECTIVES: To explore the perceived unfairness experienced by student nurses during their undergraduate clinical placements. BACKGROUND: It is important that student nurses feel supported by practice staff during their clinical placement education experiences. However, it has been reported that learners can feel ignored, unsupported and bullied by others in the clinical environment and this has a detrimental effect on their learning. It is important to understand the student nurse perspective and explore ways in which their feelings of belongingness might be enhanced in the clinical area. DESIGN: A descriptive narrative approach was used to explore the qualitative data generated by the survey and interviews. Limited closed-question survey data were acquired to explore a selection of quantified survey responses about placements and mentorship. METHODS: A survey was conducted with 1,425 student nurses from adult and mental health degree nursing pathways, across nine institutions in the North West of England, UK. Unstructured interviews were undertaken with 22 student nurses from across these nine institutions. The data generated from both methods (free-text survey responses and interview) were thematically analysed. RESULTS: There were times when student nurses felt that they had been treated unfairly by various members of the healthcare team during their clinical placements. Unfairness was related to being ignored and unsupported or being used as an "extra pair of hands" and having their supernumerary status ignored. Student nurses want to have feelings of belongingness in the clinical area and value enthusiasm for teaching from mentors. Certain positive mentor qualities were identified through the data in this study. These have been used to inform a tiered model of mentorship, to inform future thinking about student nurse education. CONCLUSION: Student nurses can feel like they are being treated unfairly in the clinical area in numerous ways. Identifying ways in which mentorship practice can be developed to adequately support education is important. This can lead to satisfaction and development on both sides of the student/educator relationship. RELEVANCE TO PRACTICE: Exploring student nurse perceptions of their learning is important when attempting to enhance educational practice in the clinical setting.

A randomized phase II trial of CRLX101 in combination with bevacizumab versus standard of care in patients with advanced renal cell carcinoma.

BACKGROUND: Nanoparticle-drug conjugates enhance drug delivery to tumors. Gradual payload release inside cancer cells augments antitumor activity while reducing toxicity. CRLX101 is a novel nanoparticle-drug conjugate containing camptothecin, a potent inhibitor of topoisomerase I and the hypoxia-inducible factors 1α and 2α. In a phase Ib/2 trial, CRLX101 + bevacizumab was well tolerated with encouraging activity in metastatic renal cell carcinoma (mRCC). We conducted a randomized phase II trial comparing CRLX101 + bevacizumab versus standard of care (SOC) in refractory mRCC. PATIENTS AND METHODS: Patients with mRCC and 2-3 prior lines of therapy were randomized 1 : 1 to CRLX101 + bevacizumab versus SOC, defined as investigator's choice of any approved regimen not previously received. The primary end point was progression-free survival (PFS) by blinded independent radiological review in patients with clear cell mRCC. Secondary end points included overall survival, objective response rate and safety. RESULTS: In total, 111 patients were randomized and received ≥1 dose of drug (CRLX101 + bevacizumab, 55; SOC, 56). Within the SOC arm, patients received single-agent bevacizumab (19), axitinib (18), everolimus (7), pazopanib (4), sorafenib (4), sunitinib (2), or temsirolimus (2). In the clear cell population, the median PFS on the CRLX101 + bevacizumab and SOC arms was 3.7 months (95% confidence interval, 2.0-4.3) and 3.9 months (95% confidence interval 2.2-5.4), respectively (stratified log-rank P = 0.831). The objective response rate by IRR was 5% with CRLX101 + bevacizumab versus 14% with SOC (Mantel-Haenszel test, P = 0.836). Consistent with previous studies, the CRLX101 + bevacizumab combination was generally well tolerated, and no new safety signal was identified. CONCLUSIONS: Despite promising efficacy data on the earlier phase Ib/2 trial of mRCC, this randomized trial did not demonstrate improvement in PFS for the CRLX101 + bevacizumab combination when compared with approved agents in patients with heavily pretreated clear cell mRCC. Further development in this disease is not planned. CLINICAL TRIAL IDENTIFICATION: NCT02187302 (NIH).

Patient-derived xenografts effectively capture responses to oncology therapy in a heterogeneous cohort of patients with solid tumors.

BACKGROUND: While patient-derived xenografts (PDXs) offer a powerful modality for translational cancer research, a precise evaluation of how accurately patient responses correlate with matching PDXs in a large, heterogeneous population is needed for assessing the utility of this platform for preclinical drug-testing and personalized patient cancer treatment. PATIENTS AND METHODS: Tumors obtained from surgical or biopsy procedures from 237 cancer patients with a variety of solid tumors were implanted into immunodeficient mice and whole-exome sequencing was carried out. For 92 patients, responses to anticancer therapies were compared with that of their corresponding PDX models. RESULTS: We compared whole-exome sequencing of 237 PDX models with equivalent information in The Cancer Genome Atlas database, demonstrating that tumorgrafts faithfully conserve genetic patterns of the primary tumors. We next screened PDXs established for 92 patients with various solid cancers against the same 129 treatments that were administered clinically and correlated patient outcomes with the responses in corresponding models. Our analysis demonstrates that PDXs accurately replicate patients' clinical outcomes, even as patients undergo several additional cycles of therapy over time, indicating the capacity of these models to correctly guide an oncologist to treatments that are most likely to be of clinical benefit. CONCLUSIONS: Integration of PDX models as a preclinical platform for assessment of drug efficacy may allow a higher success-rate in critical end points of clinical benefit.

A global assessment of the social and conservation outcomes of protected areas.

Protected areas (PAs) are a key strategy for protecting biological resources, but they vary considerably in their effectiveness and are frequently reported as having negative impacts on local people. This has contributed to a divisive and unresolved debate concerning the compatibility of environmental and socioeconomic development goals. Elucidating the relationship between positive and negative social impacts and conservation outcomes of PAs is key for the development of more effective and socially just conservation. We conducted a global meta-analysis on 165 PAs using data from 171 published studies. We assessed how PAs affect the well-being of local people, the factors associated with these impacts, and crucially the relationship between PAs' conservation and socioeconomic outcomes. Protected areas associated with positive socioeconomic outcomes were more likely to report positive conservation outcomes. Positive conservation and socioeconomic outcomes were more likely to occur when PAs adopted comanagement regimes, empowered local people, reduced economic inequalities, and maintained cultural and livelihood benefits. Whereas the strictest regimes of PA management attempted to exclude anthropogenic influences to achieve biological conservation objectives, PAs that explicitly integrated local people as stakeholders tended to be more effective at achieving joint biological conservation and socioeconomic development outcomes. Strict protection may be needed in some circumstances, yet our results demonstrate that conservation and development objectives can be synergistic and highlight management strategies that increase the probability of maximizing both conservation performance and development outcomes of PAs.

Mycotic popliteal aneurysm rupture secondary to Campylobacter fetus.

BACKGROUND: Mycotic aneurysms of the popliteal artery are uncommon. Popliteal aneurysms rarely rupture. The authors present the second reported case of popliteal artery rupture as a result of Campylobacter fetus infection. This report confirms the arterial destructive potential of C. fetus infection in a peripheral artery. METHODS: An 85-year-old male who had previously undergone endovascular abdominal aortic aneurysm repair in 2007 presented with positive blood cultures for C. fetus. No endocarditis was detected. No periprosthetic fluid to suggest aortic endograft infection was present. During hospitalization for sepsis, he developed acute right knee pain and swelling. A 5.2-cm popliteal aneurysm, with contained rupture, was found on ultrasound and confirmed by computed tomography and angiography. Recommendations for treatment and a literature review are provided. RESULTS: This patient was successfully managed with total excision of the aneurysm via a posterior approach with reconstruction through a medial approach using autologous saphenous vein bypass. Culture-directed antibiotic therapy (6 weeks of intravenous ertapenem) to eradicate the pathogen completed the therapy. The patient is doing well at 18- month follow-up. CONCLUSIONS: Mycotic popliteal aneurysm associated with C. fetus is a rare but potentially fatal condition. Isolating C. fetus should alert the surgeon to the peripheral arterial destructive potential of this pathogen, as manifested by acute rupture in this patient. Traditional resection through a posterior approach and revascularization through noncontaminated tissue with culture-directed therapy are the treatments of choice.

Endovascular repair of ruptured and symptomatic abdominal aortic aneurysms using a structured protocol in a community teaching hospital.

BACKGROUND: Open abdominal aortic aneurysm (AAA) repair has gradually been replaced by endovascular aneurysm repair (EVAR). The primary objective of this study is to establish baseline mortality data and compare our institutional mortality rates for ruptured AAA patients with published rates from institutions using similar approaches. METHODS: This study is a retrospective review of 49 patients treated using a structured ruptured AAA (rAAA) protocol in a community teaching hospital. Variables examined include demographics, repair type, device used, presenting systolic blood pressure, presenting glomerular filtration rate, initial hematocrit, transfusions required, and development of postoperative abdominal compartment syndrome. RESULTS: Forty-nine patients were treated using the rAAA protocol and 48 underwent repair. The 30-day mortality for rAAA and symptomatic AAA (sAAA) was 36.4% (12/33) and 20.0% (3/15), respectively, with a mean mortality of 31.2% (15/48). Mortality for rAAA treated by EVAR was 32.0% (8/25). Mortality for rAAA in the open repair group was 33% (2/6). Conversion from EVAR to open procedure (3/48) or 6% resulted in 100% mortality (P = 0.266). The development of abdominal compartment syndrome was an absolute predictor of death as mortality was 100% (P < 0.001). Other significant predictors of death include the following: (1) blood transfusion received during operation required in 10/14 deaths (71%) (P = 0.005) and (2) transfusion received anytime during hospitalization required in 12/14 deaths or 86% (P = 0.017). CONCLUSIONS: The management and endovascular repair of sAAA or rAAA can be improved at the community hospital level by the implementation of standardized protocols. Blood transfusions and development of postoperative abdominal compartment syndrome significantly increase mortality. Individual institutional knowledge of results is critical to effective process improvement and optimal patient outcomes.

Development and field tests of a narrowband all-reflective spatial heterodyne spectrometer.

We describe the design, development, and performance of a narrowband, all-reflective, unaliased spatial heterodyne spectrometer (SHS) that has been tested in observations at the focus of the 1.6 m main telescope of the McMath-Pierce solar telescope on Kitt Peak. The all-reflective SHS described herein is a highly robust common-path Fourier transform spectrometer without moving parts that, over a limited spectral region, combines the large field of view and high resolving power characteristic of interference spectrometers but at substantially reduced instrument size and optical tolerances. The self-scanned region of wavelength space and resolving power of the SHS are determined by the beam size, the diffraction grating groove density, the number of detector elements, and the fixed orientation of a set of pilot mirrors. The results presented here represent the first successful implementation of this reflective SHS design for field use. We discuss concepts behind the unaliased reflective SHS design and report the performance of the instrument when used to observe terrestrial airglow and absorption features, the solar spectrum, and the Jovian spectrum near λ=6300 Å, at the achieved resolving power (R=λ/δλ) of R>100,000. The results confirm that reflective SHS instruments can deliver effective interferometric performance in the visible to the far-ultraviolet wavelengths with commercial optics of moderate surface quality.

Sex-biased inbreeding effects on reproductive success and home range size of the critically endangered black rhinoceros.

A central premise of conservation biology is that small populations suffer reduced viability through loss of genetic diversity and inbreeding. However, there is little evidence that variation in inbreeding impacts individual reproductive success within remnant populations of threatened taxa, largely due to problems associated with obtaining comprehensive pedigree information to estimate inbreeding. In the critically endangered black rhinoceros, a species that experienced severe demographic reductions, we used model selection to identify factors associated with variation in reproductive success (number of offspring). Factors examined as predictors of reproductive success were age, home range size, number of nearby mates, reserve location, and multilocus heterozygosity (a proxy for inbreeding). Multilocus heterozygosity predicted male reproductive success (p< 0.001, explained deviance >58%) and correlated with male home range size (p < 0.01, r(2) > 44%). Such effects were not apparent in females, where reproductive success was determined by age (p < 0.01, explained deviance 34%) as females raise calves alone and choose between, rather than compete for, mates. This first report of a 3-way association between an individual male's heterozygosity, reproductive output, and territory size in a large vertebrate is consistent with an asymmetry in the level of intrasexual competition and highlights the relevance of sex-biased inbreeding for the management of many conservation-priority species. Our results contrast with the idea that wild populations of threatened taxa may possess some inherent difference from most nonthreatened populations that necessitates the use of detailed pedigrees to study inbreeding effects. Despite substantial variance in male reproductive success, the increased fitness of more heterozygous males limits the loss of heterozygosity. Understanding how individual differences in genetic diversity mediate the outcome of intrasexual competition will be essential for effective management, particularly in enclosed populations, where individuals have restricted choice about home range location and where the reproductive impact of translocated animals will depend upon the background distribution in individual heterozygosity.

Long-term Survivorship and Outcomes of Patients Without Dysplasia Undergoing Capsular Repair During Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: There is a paucity of literature evaluating long-term outcomes and survivorship of patients undergoing primary hip arthroscopy with capsular repair for femoroacetabular impingement syndrome (FAIS). PURPOSE: To report 10-year survivorship and patient-reported outcomes (PROs) after primary hip arthroscopy with capsular repair for FAIS and evaluate the effect of capsular repair in patients at the highest risk for conversion to arthroplasty. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed on all patients undergoing primary hip arthroscopy with capsular repair between October 2008 and February 2011. Patients with a minimum 10-year follow-up on the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale for pain (VAS) scores were selected. The preoperative and minimum 10-year follow-up Hip Outcome Score-Sports Specific Subscale (HOS-SSS) scores were also reported, if available. Patients with ipsilateral hip surgery, worker's compensation, Tönnis osteoarthritis grade >1, and hip dysplasia (lateral center-edge angle <25°) were excluded. Survivorship, PROS, and clinical benefit-minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS)-were reported. An additional propensity-matched subanalysis was performed on patients at the highest risk for conversion to arthroplasty, comparing patients undergoing capsular repair to patients with unrepaired capsules. RESULTS: A total of 145 (n = 130 patients) out of 180 eligible hips (n = 165 patients) had a minimum 10-year follow-up (80.6%). Also, 126 hips (86.9%) belonged to women, and 19 hips (13.1%) belonged to men. The mean patient age was 30.3 ± 12.9 years. The survivorship rate was 91% at the 10-year follow-up. The cohort experienced significant improvements (P < .001) in the mHHS, NAHS, HOS-SSS, and VAS for pain scores. Moreover, the cohort achieved high rates of the PASS for the mHHS (89.8%), high rates of the MCID for the mHHS (82.4%), and high rates of the MCID for VAS for pain (80.6%) scores. In the propensity-matched subanalysis performed on patients with the highest risk for arthroplasty, 29 hips with capsular repair were matched to 81 hips with unrepaired capsules. While both groups experienced significant improvements in all PROs (P < .05), the group without capsule repair trended toward a higher conversion to arthroplasty rate when compared with the repair group. In addition, an odds ratio was calculated for the likelihood of converting to arthroplasty after having an unrepaired capsule compared with capsular repair (2.54 [95% CI, 0.873-7.37]; P = .087). CONCLUSION: Patients undergoing primary hip arthroscopy with capsular repair experienced a high survivorship rate of 91% at a minimum 10-year follow-up. Patients who did not convert to arthroplasty saw favorable improvements in PROs and achieved high clinical benefit rates. In addition, among those patients at the highest risk for conversion to arthroplasty, a trend toward greater survivorship was observed with capsular repair.

Ten-Year Outcomes in Patients Aged 40 Years and Older After Primary Arthroscopic Treatment of Femoroacetabular Impingement With Labral Repair.

BACKGROUND: Arthroscopic labral repair has been shown to result in favorable short- and midterm outcomes; however, the durability of outcomes specifically in older patients remains underreported. PURPOSE: To (1) report prospectively collected hip preservation rates and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up in patients aged ≥40 years after primary hip arthroscopy with labral repair and (2) perform a matched analysis comparing patients aged ≥40 years with patients aged <40 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected and retrospectively reviewed on all patients who underwent primary hip arthroscopy between February 2008 and December 2011. Patients aged ≥40 years who underwent labral repair were included. Preoperative and minimum 10-year follow-up scores were collected for multiple PROMs. Propensity score matching was utilized to compare these patients with a cohort of patients <40 years. RESULTS: Of the 113 hips eligible, 91 hips (80.5%) on 85 patients (6 bilateral) had a minimum 10-year follow-up. There were 58 women (68%) and 27 men (32%) with a mean age and body mass index of 47.8 years and 25.8, respectively. The hip preservation rate for patients aged ≥40 years was 78%, with 20 patients requiring arthroplasty during the study period. There was significant improvement in all PROMs from baseline to minimum 10-year follow-up with high rates of achieving the minimal clinically important difference and Patient Acceptable Symptom State clinical outcome thresholds. In total, 69 patients aged ≥40 years were propensity matched to 107 patients <40 years. Patients ≥40 tended to have a lower hip preservation rate (81.2% vs 91.6%; P = .06), while patients in the younger cohort had significantly higher rates of secondary hip arthroscopy (14% vs 3%; P = .02). Improvement in PROMs was comparable between the groups. CONCLUSION: Patients ≥40 years who underwent primary hip arthroscopy with labral repair demonstrated a hip preservation rate of 78%, significant and durable improvement in PROMs, and high rates of satisfaction at a minimum 10-year follow-up. Matched analysis with patients <40 years revealed comparable improvement in patient-reported outcomes between the 2 groups, with a tendency to a higher level of arthroplasty in patients ≥40 years.